Technical information

Amateur female boxers, during the period of study, competed in three rounds of 2 min each, with 1 min of rest between two following rounds. Since 2009, following the new rules issued by the International Federation of Amateur Boxing (Association Internationale de Boxe Amateure, AIBA), female Olympic-style boxers compete in bouts of four rounds of 2 min each, with 1 min of rest between two following rounds.

On the other hand, professional female boxers still compete from 4 up to 10 rounds of 2 min each, with 1 min of rest between two following rounds. All boxers wear 10 oz (284 g) gloves and a mouth-guard during matches. Abiding Italian laws, both amateur and professional boxers are to wear breast and genitalia protectors while a head guard is mandatory for amateurs (as requested by AIBA). Head guard, however, was mandatory also for professional female boxers in Italy, from 2001 to August 2005, as requested by Italian laws.3

All abbreviations used to indicate a boxing verdict when matches are stopped before the time limit, are shown in table 1.

The data collected over the initial 7 years activity showed on increasing number of women turning to boxing. The number of female boxers is constantly increasing, from 30 to 200 in years 2001–2007 (fig. 1). Moreover, competitive results of Italian female boxers are promising, even at international levels, both amateur (one European and World confirmed Champion, and several top-ranking athletes in European championships) and professional (four European and two World champions). In table 2 are summarised trends of amateur and professional women boxers affiliated to FPI from 2001 to 2007, number of competitions and number (and decisions) of matches stopped before time limits.

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Figure 1

Female boxers in Italy from 2001 to 2007.

Boxing female activity in Italy from 2002 to 2007: retrospective study

As a whole, in the time span from 1 January 2002 to 31 December 2007, we collected data on 5600 medical examinations carried out in official competitions (2800 before and 2800 after competition). All prematch declarations were normal, as well as all pregnancy laboratory tests. In short, there was no declared recent or ongoing vaginal bleeding (other than normal menses), known pelvic tumourous masses, genital urinary symptoms or recent surgery and/or trauma.

Upon precompetition examination, only three amateur athletes (0.11%) complained of minor conditions: mild hyperemia of the right eye, one bruising in the zygomatic region in the second and an evident haematoma in the ocular soft tissue of the left eye in the last case, who was not allowed to take part in the competition.

After competition, medical examination was negative in 2749 cases (98.2%): in 51 exams in actions (1.8%, fig. 2), the following clinical conditions were highlighted:

• ▶ Twenty-two cases (21 amateur and 1 professional) for mild soft tissue contusion in the face (minor haematoma or ecchymosis in the zygoma, peri-ocular soft tissue and eyelid arm and shoulder).

• ▶ Twelve cases (11 amateur and 1 professional) suffered epistaxis, one with right inferior eyelid ecchymosis, one with left inferior eyelid ecchymosis, one for nasal bones fractures.

• ▶ In 11 cases (all amateur), mild contusion to the upper limb (hand, wrist and/or shoulder) was observed.

• ▶ Two amateur boxers had minor facial bruises not requiring surgery.

• ▶ Two professional athletes had periorbital lacerations that required suturing.

• ▶ Mild contusions to the lower limb were observed in three amateur boxers.

• ▶ One amateur athlete, who lost by knock-out (KO) after having received a blow to the nose, suffered a fracture to the nasal pyramid, and she was sent to the hospital for further assessment.

• ▶ One amateur athlete, who lost by KO after having received a blow to the head, lost consciousness for a few seconds. Complying with the rules of FPI medical section, also applicable to male boxers, in the events of blows to the head resulting in suspect head concussion (or more severe neurological conditions), the athlete was sent to hospital: however, she refused hospitalisation and denied further clinical examination and MRI of the brain when contacted 1 month later.

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Figure 2

Medical problems after 2800 competitions disputed by female boxers.

No haematoma, ecchymosis or cysts were found in mammary region, and athletes did not report abdominal or pelvic acute conditions after competitions.

Boxing female activity in Italy from 2002 to 2007: Prospective study within Lazio Region

From 1 January 2002 to 31 December 2007, 61 amateur athletes (mean age 24.14±4.13 years) were affiliated as “female boxers” with FPI in the Italian Region Lazio and, therefore, subject to medical tests as specified by Italian laws.1 5 One particular athlete applying for affiliation was excluded from our study because she underwent aesthetic breast surgery in 2001, with positioning of prosthesis. Complying with the 2001 Italian law,3 in force at that time and confirmed by the new law in 2005,5 she was declared not eligible for competitive boxing.

During 84 months (mean follow-up 31.3±17.2 months), 40 athletes out of 61 (65.6%) took part in official competitions (ranging from 1 to a maximum of 35 bouts), for a total amount of 296 competitions (4.4±4.5 matches per boxer), which were stopped before the time limit in 18 cases (6.1%, 13 referee stop contest outclassed (RSCO), 4 referee stop contest head (RSCH) and 1 KO). No athlete was presented more than once in RSCH and/or KO verdicts.

Out of 61 athletes examined during follow-up, 32 underwent more than one medical examination either for yearly re-affiliation (28 cases) or for re-admission after loosing a competition before the time limit (referee stop contest (RSC), RSCH, abandon).1

One athlete, who lost by KO and had a fracture of nasal pyramid (see previous chapter), did not show up for the medical examination for re-admission and had decided to give up competitive boxing.

Mammary area

During the first visit, after clinical examination, diagnostic ultrasound and radiogram (when obtained), signs of fibrocystic mastopathy were showed in 9 out of 61 athletes (14.7%), even though these conditions are not to be considered harmful to boxing activities, according to the breast specialists consulted by FPI. Out of the nine athletes with positive findings, follow-up was possible only in three cases showing no changes either in radiological and clinical appearance.

Out of the 32 athletes who underwent more then one medical examination over the 84 months of our study, two cases, during yearly re-affiliation tests, were found by ultrasound to have developed a small fibroadenoma. Both athletes were declared eligible to boxing, according to the breast specialist consultants of FPI, although with a mandatory check-up every 6 months which showed no considerable change in size over the time (follow-up of 30 and 62 months, respectively).

One athlete, at echography for yearly re-affiliation, showed three small cystic lesions in the upper sectors of the left breast. When checked again in the following 3 months with subsequent echo scans, given the changes in size of such lesions along the menses and after consulting the breast specialist and endocrinologist, she was granted eligibility for 6 months (see following paragraph).

Reproductive system

At their first visit, all athletes reported regular menses as rhythm, quantity and duration, and they had menarche at the age of 12.4±1.0 years. Two athletes (3.3%) reported to be on oral contraceptive, and none of them had ever carried out any pregnancy.

Examination of reproductive system was negative in all cases, but echography revealed an ovarian cyst in two athletes (3.3%): in both cases, FPI consultants, once performed additional tests, decided this condition did not contraindicate boxing activity.

Among the 32 athletes who underwent more than one medical examination during the period of our study, a pelvic ultrasound only confirmed one ovarian cyst, unchanged in size, in one of the two athletes who showed such finding in their first examination. Although in the second athlete, the size of the cyst did not change (maximum diameter 22 mm) but oligo-amenorrhea occurred, she was sent for surgery after consulting her gynaecologist, because pharmacological treatment was not effective. Six months after surgery, she started training again and took part to five competitions (two wins, three losses by the score), without any problems related to the reproductive system (follow-up 40 months).

One athlete, with unremarkable gynaecologic findings at the first examination and ultrasound, was discovered to have a small left ovarian cyst in subsequent echography to the purpose of yearly re-affiliation. As this cyst changed size along the menses, as it happens in functional cysts, a yearly eligibility was granted. She did not report any troubles related to the reproductive system in a follow-up of 48 months; in the meanwhile, she took part to 25 competitions (13 wins, 1 draw, 11 losses by the score).

At the re-affiliation examination, one athlete who fought in two competitions over 12 months (one win, one loss, both by the score) reported polymenorrhea. Pelvic ultrasound showed an intramural myoma (maximum diameter 14 mm) which was not found in her previous examination. Such condition did not contraindicate competitive boxing, according to the specialists, although she was asked to have pelvic ultrasound check every 6 months. This athlete, however, decided to discontinue competitive boxing, and no more data are available about her condition.

Lately, at yearly re-affiliation, one athlete showed ovarian polycystosis by ultrasound, which was not found 12 months earlier: she is the same athlete also showing small mammary cysts, suffering, moreover, from hypothyroidism on pharmacological treatment. After consulting the specialists in endocrinology and gynaecology, she was granted eligibility, although on a 6-month basis, to better evaluate her clinical and laboratory history. At this time, we do not have any further follow-up information data for this athlete.

Nervous system

At their first visit, neurological examination was normal in all 61 athletes, while the EEG showed “non-specific anomalies” in four cases (6.6%).

In one athlete, we decided to postpone eligibility and take a second EEG after 6 months, which confirmed the same anomalies. We asked the athlete to take MRI of the brain that showed normal results, and she was re-admitted to competitive boxing. Subsequent EEGs and examinations for yearly re-affiliation did not show any worsening of EEG anomalies, although she had intense competitive activity (27 matches over 4 years, 14 wins, 1 draw, 3 losses by RSCO, 1 WO and 8 losses by score).

MRI was also obtained in the three further cases showing EEG “non-specific anomalies” in their first exam. Two of them did not show any anomalies of note to cranial-encephalic and cerebellar areas and eligibility was, therefore, granted (by now, we do not have any further follow-up information). The third one is still suspended from competitions as she is waiting to take her MRI.

One athlete (included in our previous study) was found to have non-specific EEG anomalies upon her re-admission after losing a competition by RSCH: she also showed, as neurological finding, first degree nystagmus when looking leftwards and right-side deviation in the straight marching test. We requested MRI, which was normal. Because her neurological findings and EEG anomalies subsided, she was granted eligibility to competitive boxing. Since then, she has taken part to additional 18 competitions, 4 wins, 2 draws, 12 losses (1 by RSCO, 11 by the score), and neither EEG anomalies nor neurological signs were found at her subsequent three yearly re-affiliation examinations.

The three athletes who lost before the time limit (one RSC, two RSCH) did not show any adverse neurological signs. The athlete who lost by KO and reported nasal bones fracture did not apply for re-affiliation; therefore, she did not undertake any further examination.

The eye

At their first examination, 16 athletes out of 61 (26.2%) had myopia, which was moderate in six of them (overall visual acuity of 8/10, with at least 4/10 at each eye): they were all granted eligibility but were compelled to wear soft contact lenses during training and competition. One athlete out of the 16 myopic athletes was disqualified from competitive boxing for a high-degree myopia (non-corrected visus in left and right eye of 1/50), as provided by the medical rules of FPI.

Fundus oculi showed a mild dystrophia of lower peripheral retina in one athlete with high-degree myopia (non-corrected visus in the left and right eye of 1/10), although it was judged non-significant to practice boxing. Another athlete with high-degree myopia (1/10 not corrected visus in both eyes) showed signs of successful therapeutic laser for peripheral retinal degeneration and microlesions. This case was also judged to be eligible to competitive boxing. Last, a mild inferior retinal dystrophy was found in a young woman with normal visus, although not contraindicating competitive boxing, along with ophthalmologists' opinion.

A paving stone degeneration in the upper retina was demonstrated at first examination in one athlete with moderate myopia (non-corrected visus in the right and left eye 1/10). After consulting the eye specialist, we decided to grant eligibility only for 6 months to follow properly such condition. We do not have further data regarding this athlete, as she still has to take her control examination.

In the study period, two athletes out of six with moderate myopia had surgical treatment (photorefractive keratotomy) with a good outcome, and they reached, respectively, not corrected visus of 10/10 in the right eye and 9/10 in the left eye in one athlete, and 9/10 in both eyes in the other athlete.

Fundus oculi confirmed mild dystrophia of the lower retina in the athlete who showed such findings in her first examination. This young woman came back for yearly re-affiliation, and she took part to six competitions during the year (four wins, two losses by the score). In the second athlete with dystrophic retina and normal visus, the latest fundus oculi examination was normal.

Along a follow-up of 13 months, one athlete who took part to three matches (one win, two losses by the score) at fundus oculi examination showed a vitreoretinal adhesion in the right eye, although our consulting ophthalmologists did not consider it an excluding criterion for competitive boxing.

In one more athlete (follow-up 54 months, 21 competitions, 14 wins, 5 losses by the score, 2 losses by RSCO), fundus oculi examination demonstrated a new area of hyperpigmentation in the middle peripheral retina of the right eye, also judged of no importance by consultants.

Peri-ocular soft tissue, lenticular apparatus and eye tonometry were normal in all athletes both at first examination and at their last visit.

Ear, nose and throat

At their first examination, one athlete showed a mild bilateral tympanic retraction and a mild bilateral transmissive hypoacusia at high frequencies. The finding of mild bilateral high-frequency hypoacusia was also demonstrated in one more athlete (2 out of 61, 3.3%). In both cases, such anomalies did not contraindicate competitive boxing, although only the first of the two athletes (follow-up 25 months) took part to official competitions, fighting only one match (lost by the score). Subsequent otoscopy and audiometry were unchanged in this athlete at yearly re-affiliation examination.

Among the 61 athletes examined, four (6.6%) showed signs of fracture of nasal pyramid at their first examination, while nasal septum was found to be mildly deviated in 26 of them (42.6%). Four cases (6.6%) had signs and symptoms of rhinitis probably on allergic basis (pollinosis) also found in other four athletes at yearly re-affiliation examination. Mild hypertrophy of lower turbinates was found in 22 athletes (36.1%) at first examination and in 17 during follow-up, two of them with previous normal findings.

At re-admission examination, one athlete with nasal pyramid previously normal and not deviated nasal septum was found to have signs of past fracture of nasal bones and mild septum deviation, which she suffered in a match lost by RSCH. Nasal septum deviation was newly found also in one athlete at yearly re-affiliation examination (18 competitions during 24 months of follow-up, 4 wins, 2 draws and 12 losses by the score).